扩张器注射壶安置方式对耳后扩张器置入术后并发症发生的影响及处理策略

扩张器注射壶安置方式对耳后扩张器置入术后并发症发生的影响及处理策略

葛鋆王永振钟群珍陈程

本文来源：《中华整形外科杂志》2023年2月第39卷第2期

DOI:10. 3760 / cma.j.cn114453-20230119-00009

作者单位：中山大学孙逸仙纪念医院整形外科，广州510288

通信作者：王永振，Email: md_wang@126.com

引用本文

葛鋆, 王永振, 钟群珍, 等. 扩张器注射壶安置方式对耳后扩张器置入术后并发症发生的影响及处理策略 [J] . 中华整形外科杂志, 2023, 39(3) : 245-251. DOI: 10.3760/cma.j.cn114453-20230119-00009.

【摘要】

目的探讨扩张器注射壶安置方式对耳后扩张器置入术后并发症发生的影响及处理对策。

方法回顾性分析2016年1月至2022年8月中山大学孙逸仙纪念医院整形外科行耳后扩张器置入术的小耳畸形或先天性耳廓缺损患者临床资料。应用扩张法耳廓再造术重建耳廓，一期行耳后扩张器置入术。按照扩张器注射壶放置情况，分为扩张器注射壶内置组(简称"内置组")与扩张器注射壶外置组(简称"外置组")。术后常规注水扩张，扩张器置入术后即刻至二期手术前随访观察2组患者的耳后扩张器术区情况及相关并发症发生情况。2组间各种并发症的发生率比较采用卡方检验，P<0.05为差异有统计学意义。

结果共纳入51例患者，男42例，女9例，年龄5~43岁，平均13.1岁；左侧19例，右侧31例，双侧1例。内置组21例，外置组30例。2组患者均行扩张期内随访1~3个月。2组患者扩张器置入术后共有19例出现血肿、感染、皮瓣血运异常、扩张器外露、扩张器损坏并发症；内置组发生并发症6例，其中单纯血肿3例，扩张器外露3例；外置组发生并发症13例，包括单纯血肿5例、单纯扩张器感染2例、扩张器损坏1例、血肿合并感染2例、感染合并扩张器外露1例、皮瓣血运异常合并扩张器外露1例、血肿合并皮瓣血运异常及扩张器外露1例。上述所有并发症患者经治疗后按期或提前完成耳廓再造二期手术，术后效果良好。外置组的感染发生率高于内置组[28.57%(6/21) vs. 43.33%(13/30)]，差异有统计学意义(χ2＝3.88，P＝0.049)；2组间血肿(χ2＝1.12)、皮瓣血运异常(χ2＝1.46)、扩张器外露(χ2＝0.22)、扩张器损坏(χ2＝0.71)发生例数分别比较，差异均无统计学意义(P均>0.05)。

结论扩张器注射壶外置会增加术后感染发生率；两种注射壶安置方式对耳后扩张器置入术后血肿、皮瓣血运异常、扩张器外露、扩张器损坏等并发症发生率无明显影响；但两种方式对应的并发症特征有所不同，临床治疗及护理策略也有所差异。

【关键词】组织扩张；手术后并发症；先天性小耳；注射壶内置；注射壶外置

基金项目：广州市科学技术局科技计划项目（202201011447）

The influence of expander injection port placement on complications of retroauricular soft tissue expander implantation and treatment strategy

Ge Jun, Wang Yongzhen, Zhong Qunzhen, Chen Cheng

Department of Plastic Surgery, Sun Yatsen Memorial Hospital, Sun Yatsen University, Guangzhou 510288, China

Corresponding author: Wang Yongzhen, Email: md_wang@126.com

【Abstract】

Objective To explore the influence of expander injection port placement on complications of retroauricular soft tissue expander implantation and put forward the corresponding treatment countermeasures.

Methods Data of the patients with congenital microtia or acquired ear defects who were treated in the Department of Plastic Surgery of Sun Yat-sen Memorial Hospital from January 2016 to August 2022 were retrospectively analyzed. All patients underwent ear reconstruction with skin expansion. According to the placement of the expander injection port in the operation, all patients were divided into the group of internal expander injection port (referred to as the internal group) and the group of external expander injection port (referred to as the external group). After the operation, patients of these two groups underwent skin expansion. The general information of the local region and the occurrence of related complications were observed in both groups. Chi-square test was used for statistical analysis.

Results A total of 51 patients were included in this study, including 42 males and 9 females, with an average age of 13.1 years from 5 years old to 43 years old. There were 19 cases of left side, 31 cases of right side, 1 case of both sides. There were 21 cases in the internal group and 30 cases in the external group. There were 19 patients in total who suffered complications such as hematoma, infection, ischemic necrosis of the flap, expander exposure and expander damage. Complications occurred in 6 cases in the internal group, i. e., hematoma in 3 cases and expander exposure in 3 cases. And complications occurred in 13 patients in the external group, including hematoma in 5 cases, infection in 2 cases, expander damage in 1 case, hematoma combined infection in 2 cases, infection combined expander exposure in 1 case, ischemic necrosis of the flap combined expander exposure in 1 case and hematoma combined ischemic necrosis of the flap and expander exposure in 1 case. Patients with all the above-mentioned complications received the second-stage auricle reconstruction surgery on schedule or ahead of schedule after treatment of the complications, and the postoperative effect was good. The incidence of infection was higher in the external group[28.57%(6/21)vs.43.33%(13/30)], and there were significant differences in the incidence of infection between the two groups (χ2=3.88, P<0.05), but no significant differences in hematoma (χ2=1.12, P>0.05), ischemic necrosis of the flap (χ2=1.46, P>0.05), expander exposure (χ2=0.22, P>0.05) or expander damage (χ2=0.71, P>0.05).

Conclusion External expander injection port can increase the incidence of postoperative infection. The expander injection port placement does not significantly influence on the incidence of complications such as hematoma, ischemic necrosis of the flap, expander exposure and expander damage. However, the characteristics of these complications in the two kinds of injection port placement are different, and there are some differences in their treatment countermeasures.

【Key words】Tissue expansion; Postoperative complications; Congenital microtia; Internal expander injection port; External expander injection port

Fund program: Guangzhou Science and Technology Project from Guangzhou Municipal Science & Technology Bureau（202201011447）

Disclosure of Conflicts of Interest: The authors have no financial interest to declare in relation to the content of this article.

Ethical Approval: This study was approved by the Medical Ethics Committee of Sun Yat-sen Memorial Hospital, Sun Yat-sen University（SYSKY-2022-554-01)

皮肤扩张法耳廓再造自20世纪80年代末首次被应用以来[1]，已经形成了成熟的手术方案，在耳廓再造领域有了越来越多的应用。皮肤软组织扩张器置入耳后皮下或筋膜下，可为耳廓再造手术提供面积更大、厚度更薄的无毛区皮肤，利于耳廓再造二期手术中的支架覆盖，可使再造耳亚结构清晰、增加再造耳廓的立体效果[2]。同时，由于手术置入区域及层次较为恒定、耳后解剖结构稳定、患者数量较大，所以对扩张器置入术后并发症的病因分析、治疗及护理等提供了良好的观察条件。目前耳后扩张器置入术有扩张器注射壶内置、外置2种方式[3,4]，为了比较这2种术式的并发症发生的差别，我们对2016年起收治的全部耳后扩张器置入患者的并发症进行分析，并提出治疗及护理建议。

资料与方法

一、资料选择

回顾性分析2016年1月至2022年8月中山大学孙逸仙纪念医院整形外科收治的小耳畸形或后天性耳廓缺损行耳后扩张器置入术的患者临床资料。

纳入标准：(1)先天性小耳畸形或后天性耳廓缺损；(2)既往未行任何形式的治疗；(3)应用扩张法耳廓再造术重建耳廓，一期行耳后扩张器置入术。排除标准：(1)失访；(2)一期扩张器置入术后未进行后续手术。

按照扩张器注射壶安置情况分为2组：扩张器注射壶内置组(简称"内置组")和扩张器注射壶外置组(简称"外置组")。

本研究已通过中山大学孙逸仙纪念医院医学伦理委员会批准(SYSKY-2022-554-01)；患者及家属对本研究知情并签署知情同意书，同意将其资料用于本研究。

二、治疗方法

(一)手术方法

1．扩张器注射壶内置法扩张器置入术(图1)

术前于患耳耳后标记略大于扩张器投影面积的手术范围及切口。患者平卧位，采用全身麻醉或局部麻醉。暴露患耳术区后常规消毒术区，铺巾、单。以含有1∶20万肾上腺素的0.2%利多卡因局麻药进行术区的局部浸润麻醉。于设计切口处切开皮肤至颞浅筋膜(耳后筋膜)浅面，于标记范围内的皮下浅层做潜行锐性分离，形成略大于扩张器投影面积的皮下腔隙，以安置扩张器囊腔。于该腔隙后外侧颈部皮下钝性剥离出扩张器注射壶安置腔隙。电凝彻底止血后，将检查无漏气的50 ml或70 ml扩张器及注射壶分别置入相应腔隙内，并放置1根F14#引流管，分层缝合皮下、皮肤。即刻于扩张器内注射无菌生理盐水8~10 ml。以无菌纱布、棉垫、绷带包扎，引流管接负压引流瓶。

2．扩张器注射壶外置法扩张器置入术(图2)

手术方式与扩张器注射壶内置法扩张器置入术类似，其不同点为无需剥离扩张器注射壶安置腔隙，扩张器注射壶经手术切口留置于体外。

(二)扩张注水

1．注水方案

如前所述，术中扩张器内注射无菌生理盐水8~10 ml。术后12~15 d开始再次注水。之后每2天注射1次生理盐水5~8 ml，总注水量达扩张器容积的1.2~1.3倍时停止扩张注水。停止注水3~4周后行二期手术。

2．注射方法

(1)内置组：以手扪及注射壶定位准确后，碘伏常规消毒皮肤，用1 ml注射器针头穿刺皮肤直入注射壶，回抽通畅后按注水方案向内注射适量生理盐水，至扩张器表面皮肤张力适当。注射完成15 min检查患者扩张皮瓣无血运障碍后，方可让患者离开。(2)外置组：碘伏消毒扩张器注射壶后，直视下直接穿刺注射壶注水，余注意事项同内置组。

三、术后随访

扩张器置入术后即刻至二期手术术前随访观察2组患者有无血肿、感染、切口裂开、皮瓣血运异常、扩张器外露、扩张器损坏等并发症。

四、统计学分析

采用SPSS 19.0软件进行统计分析，统计2组患者的并发症发生例数及发生率，计数资料采用例数(百分数)描述，2组间比较采用卡方检验，P<0.05为差异有统计学意义。

结果

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